When clients second-guess me, I practice the art of being gracious. It doesn’t matter that I spent tens of thousands of dollars earning a doctorate in veterinary medicine, honed my surgical skills over countless hours, journeyed many miles to attend lectures by experts in the field, maintained my licenses to prescribe controlled substances or earned the accreditation necessary to write health certificates for animals to travel.
My Gracious Project is for my inner peace. I am willing to trade my pride and righteous indignation for the delicious freedom of detachment. Here are some of my stories.
No, No, No, Yes
Coco, a 6-year-old female spayed goldendoodle, presented with bloody diarrhea and conveniently provided us with evidence of her condition while waiting in the exam room. Her total-body alopecia resembled a Sphinx cat, and I knew I was in for a workout when Mrs. Client explained that Coco’s baldness resulted from being bred too much when she was younger.
My job, however, was to help restore Coco’s dignity and her owner’s sanity by bringing back solid bowel movements. To that end, we ran a fecal floatation, which came back negative for intestinal parasites. A complete blood count and serum chemistry panel were normal. The owner said she didn’t think Coco had been fed table scraps, but she wasn’t sure.
Coco got a Simparica Trio heartworm-prevention tablet about one week earlier but wasn’t on the medication monthly, as prescribed. Meanwhile, the client’s other dog had been diagnosed with hookworms and wasn’t on heartworm prevention. This got my attention since the Simparica dose could have dewormed Coco initially for hookworms and caused the negative fecal result. Veterinary parasitologists recommend that deworming be repeated in two to three weeks to ensure complete results.
Next, a lipase test for pancreatitis came back strongly positive. Finally, I had something to hang my hat on.
Armed with a handout explaining pancreatitis and cost estimates for inpatient and outpatient treatment, plus fenbendazole oral suspension for deworming, I embarked on explaining my treatment plan.
My 49-pound patient’s dose of Panoquell-CA1 for pancreatitis cost several hundred dollars, so the client was understandably concerned about the expense. She said she needed to ask family members whether they could help her with the veterinary bill.
So began the bargaining process, where Dr. Wolfe wracked her brain to come up with creative ways to treat the pet and save the client money. I probably changed the estimate three times. A couple of hours later, I was flabbergasted upon hearing the verdict. Mrs. Client declined the dewormer because, she said, her father was “in the business” and could get it elsewhere. Also declined were subcutaneous fluids because Coco was drinking water, so, in her mind, that step wasn’t necessary.
“Did you read the handout?” I asked, because the document stressed the need for fluids to flush out the pancreas. Her response was a curt brushoff.
Although Coco had not vomited, she had not eaten, either. Her owner declined maropitant for nausea. Heck, she declined just about everything, including my advice. I pondered for a beat. My choice was to either pout and hold a grudge or swallow my pride and do something that might help.
I offered metronidazole antibiotic for an inflammatory bowel, Diagel oral antidiarrheal and a buprenorphine injection for abdominal pain. Bingo! We reached common ground.
I returned with the medication and a smile. “What kind of dewormer will you use?” I asked. “Make sure it will cover hookworms, and make sure you repeat it in two weeks.”
The client eagerly agreed.
“I would stick to a bland diet until Coco’s diarrhea resolves,” I added. “I’ll make a list of things to feed her.”
A Suitable Alternative
A couple who smiled a lot, talked a lot and knew what they wanted me to do exactly arrived with an 11-year-old Labrador. Sheru had been limping on his hind leg for a few days. When we walked him around the clinic, the limp was barely perceptible. Mrs. Client said he was doing a lot better than at home.
My exam led me to conclude that Sheru had a soft-tissue injury that would likely respond to anti-inflammatory medication and restricted activity. I told his owners I wanted to check his bloodwork to make sure carprofen wouldn’t put him at risk.
We call our most basic “budget” CBC and chem panel a pre-anesthetic profile. When Mrs. Client saw “pre-anesthetic,” she seemed to connect it with surgery. “I am in the medical field,” she said, “and I know it’s different for humans than animals, but I don’t believe he needs bloodwork. I would rather just get the pain medication.”
Feeling unheard, I repeated that I needed to check Sheru’s liver and kidney enzymes before prescribing carprofen. Then, my gracious side stepped forward.
“What we can do is try gabapentin because it doesn’t have as many side effects,” I offered.
The clients jumped on it, and I didn’t burn a bridge.
Unfinished Business
As a young veterinarian, I might have let a family of three clients put me on the defensive, but the owners of Mickey, a 4-year-old miniature poodle, didn’t shake my confidence. Mickey was non-weight-bearing on his hind leg after horsing around with his housemate dog buddy. The clients said he landed on the leg and then yelped in pain.
I told them I wanted to administer a pain injection to relax him for radiographs and limb palpation. Mr. Client said they had already given pain medicine. I explained that the medication I wanted to use would relax Mickey so that I could examine his stifle joint for a possible cruciate ligament injury.
The clients consented, but the dose of butorphanol laced with acepromazine left Mickey alert enough to tremble and cause uncertainty about my diagnosis. I returned to the exam room and said I might have felt some joint laxity but that my diagnosis was inconclusive and that I couldn’t rule out a partial ligament tear. My plan was to treat him with carprofen and gabapentin and restrict him from running, jumping and climbing stairs for two weeks. I recommended they consult an orthopedic surgeon if they didn’t see an improvement.
One of the clients, unsatisfied with my findings, questioned me about my palpation. I repeated what I said.
“Can’t you do the surgery here?” asked Mr. Client.
“No,” I responded.
The other clients asked about bandaging or bracing the leg, and I told them my judgment was to leave it open.
They didn’t seem happy. I couldn’t control their feelings, but I could control my confidence in my recommendations.
Calm graciousness is my goal, and my clients are free to take or leave my advice. I always make sure to give them their money’s worth.
INSPIRATIONAL WORDS
As I wrote this column, the refrain from an old Pam Tillis country song called “Let That Pony Run” came to mind. Once I consider a patient’s situation and make my recommendation, the pet owner is as free as an unbridled horse to accept or reject it. The refrain below describes my philosophy as it relates to this article.
You do what you gotta do
And you know what you know
You hang on till you can’t hang on
Then you learn to let go
You get what you want sometimes
But when it’s all said and done
You do what you gotta do
Then you let that pony run